What is the name of the useless bit at the end of a penis? A man of course, but circumcision is no joke. If you crave controversy, choose a topic concerned with sex or religion. The ancient ritual of circumcision meets both criteria. In the second century BC, tribes on the Red Sea, now Egypt, practised both female and male circumcision. One possible explanation relates to the belief that gods were bisexual and humans, like gods, had both a female and a male soul. The man's female soul which resided in the prepuce and the woman's male soul which resided in the clitoris had to be removed for healthy gender development.1 An alternative theory is that female circumcision was a means for men to control women's sexuality. Islam is opposed to female circumcision and Muslims attribute its continued practice in some Africa countries to traditional custom, not to religion. The modern re-naming of female circumcision as female genital mutilation is a clear ethical statement opposing this practice.

Male circumcision, unlike female circumcision, is incorporated into major religions. Neonatal circumcision is practised routinely by Jews, Muslims and some African Christians while adolescent circumcision is a common tribal manhood initiation ceremony. The World Health Organization estimates that 650 million or 30% of all males aged over 14 are circumcised, 70% of whom are Muslims.1 That the bizarre mutilation of ritual male circumcision is so customary suggests some deep significance. There seem to be insufficient health benefits for circumcision to have evolved through natural selection. Freud suggested that circumcision represented a metaphorical ritual castration of the son by his father to control the son's Oedipal rivalry.

Whatever the veracity of psychological explanations for male circumcision, its historic and geographic spread is intriguing. The ancient Greeks hated circumcision and the practice consequently declined under Greek rule. From about 1900, however, male circumcision became common in the United States, Australia and other English-speaking countries. In the UK there was a clear social gradient. It was purportedly impossible for a boy to attend Eton with either his foreskin or his tonsils intact.

Neonatal circumcision, whether religious or cultural, was often performed without either analgesia or anaesthetic. This further example of our barbaric denial of neonatal pain, following neonatal surgery for pyloric stenosis and other conditions, is now unconscionable. A Cochrane meta-analysis shows that dorsal penile nerve block and, to a lesser extent local anaesthetic cream, is markedly superior to placebo.2 Inadequate pain relief for circumcision persisted into the 1990s but is no longer tenable.

What happens to the foreskin after circumcision? Many are discarded but intriguing uses include incorporation into face creams and anti-ageing cosmetics, skin grafts, and as the foreskin fibroblast cell lines to feed stem cells, grow viruses and produce beta-interferon. In Africa, the foreskin may be dipped in brandy and eaten by the patient or the circumciser.1

There are some controversial medical benefits of male circumcision. In Africa, male circumcision halves the risk of a man acquiring HIV heterosexually.3 Infant male circumcision reduces the risk of urinary tract infection (UTI) significantly, but because only 1% of normal boys has a UTI, 111 boys need to be circumcised to prevent one UTI. Since 2% of circumcisions are complicated by infection or haemorrhage, therapeutic circumcision should be reserved for boys with recurrent UTI or severe vesicoureteric reflux.4 There is no evidence that circumcision improves hygiene, although this and the fond belief that it prevented masturbation were the main motivating factors in twentieth-century Western countries.

Circumcision is a rich ethical topic. Should the autonomy of an infant to choose when he is older outweigh his parents' right to choose to have their infant son circumcised? Who should pay? Non-therapeutic circumcision is rarely publicly funded. The RACP is revising its recommendations on circumcision, but previously did not recommend routine male circumcision, while acknowledging that informed parental choice should be respected. Circumcision is a topic for endless debate. But no laughing matter.

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